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Our Lady of Fatima University Research and Development Center
Nursing Management
Nursing Management of a Patient with Calyceal Calculi
A Case Study by
Alojado, Christine Mae B.
Cueva, Paulyn
Dalisay, Inah Joy
4Y1-7 (Group 7A)
Our Lady of Fatima University
Valenzuela City Campus
Mrs. Elisa Lasanas, RN, MAN
Clinical Instructor
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Our Lady of Fatima University Research and Development Center
Nursing Management II
Nursing Management of a Patient with Calyceal Calculi
Mr. D. B. A, a 30 year-old male, married Filipino from Pussian Alcala
Cagayan, had a chief complaint of left flank pain. One year prior to
admission patient DBA has positive occasional flank pain associated w/
dysuria, hematuria and passage of stone. No consult was done and no
medication taken. One month prior to admission of flank pain, the patient
consulted to a private physician and was given Ciprofloxacin 500g/tab, BID
×7 days w/c provided temporary relief. Two weeks prior to admission KUB-
UTZ was requested, revealing an inferior Calyceal Calculi, causing mild
superior calicetasia. Other, medications were also given K+ Citrate, 1TAB
TID and Sambong capsule, 1tap TID. One day prior to admission, due to
resistance of flank pain, patient was subsequently referred to Armed
Forces of the Philippines Medical Center where further medical evaluations
were done. Hence, admission was made.
In understanding the formation of calyceal calculi, we shall know
that kidney is important part of the body. Their function is to remove
waste and toxic substances from the blood and passing out the liquid
called urine. The journey of urine starts from the kidney to the bladder
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through ureter then exit to urethra. If there is more waste material in the
urine, these substances form crystals and then finally calyceal calculi.
The stone may develop usually because of the super-concentrated
urine. The other cause that can form the stone is if the output of a given
chemical waste products are increased. For instance, the calcium stones
may occur when there is too much supplement of the calcium and urine is
full of calcium. This also depends on the capacity of absorbing the calcium
from the intestines. Some people may have overactive parathyroid glands
called hyperparathyroidism which results in calcium being leached out of
the bones and getting collected in the urine.
The other chemical compounds that can form the calculi include uric
acid and the cystine, an amino acid. The calcium gets combined with
either phosphate or oxalate. Any type of obstruction to the flow of the
urine can also increase the chances for stone formation. Kidney stones
associated with infections are known as “infectious stones”.
The age group which is affected the most begins after 40 year and
continues up to 70 year. The person with one stone is likely to develop
more stones.
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Nursing Management
III
Pathophysiology
In understanding the formation of the calyceal stone, we must be
able to know first the anatomy and physiology of the urinary system. The
glomeruli of the kidneys filter about 1% (10 g) of the total body calcium
each day. Only the ultrafilterable calcium crosses the glomerular
basement membrane. The ultrafilterable calcium is the free or ionized
calcium (47%) plus a small amount (6%) which is complexed to
phosphates and citrates. Of the filtered calcium, 98% is reabsorbed by the
renal tubules. The proximal tubules are responsible for 65%, the ascending
loop of Henle for 20-25% and the distal tubules for 10%. The calcium in
the tubular fluid is nearly all ionized. Calyceal stones are found in the
funnel shaped area called the calyx between the kidney and the ureter.
The pathogenesis of calyceal stones is mainly explained with
different factors. These factors are the following (1)Deficiency of citrate,
magnesium, nephrocalcin, uropontin which is responsible to prevent
crystallization in the urine (2) Fluid volume deficiency (dehydrated patient)
incline stones to occur more often (3) Infection, urinary stasis, periods of
immobility causes slow renal drainage and alters calcium metabolism (4)
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Increase calcium concentrations in blood and urine promote precipitation
of calcium (5)Neurogenic bladder, foreign bodies, recurrent UTI’s lead to
infection stones (6) inflammatory bowel disease causes increase
absorption of too much oxalate. All of these factors lead to formation of
stones. When calculi are already formed, it causes trauma to the urinary
tract & irritate the cellular lining. Thus, it makes the patient feel flank pain
(Myers, Neighbors et al, 2006). The calyceal stones may destroy the
nephrons causing excruciating pain and discomfort. Moreover, Calyceal
calculi development blocks the flow of urine causing obstruction.
Obstruction may distend the renal pelvis and proximal ureter causing
hematuria, renal colic, and nausea and vomiting. In addition, obstruction
Increase hydrostatic pressure and causes urinary retention
As for the possible risk factors, calyceal calculi are much more
common in men than in women. Men generally have a larger muscle mass
than women. Hence they have more of the daily breakdown and rebuilding
of tissue that result in metabolic waste. And an increase in metabolic
waste predisposes people to stone formation (Curhan, Gary C., 2003).
Likewise, men generally eat more meat than women do (Curhan, Gary C.,
2003). Aside from that, if one or both of your parents made stones, there
is a greater chance that you will make stones (Rodman & Sosa).
Furthermore, fat malabsorption can lead to an increased net oxalate
absorption and, finally, to increased urinary oxalate (Seidman & Jones)
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Nursing Management
IV
History
According to the patient during the interview, he was admitted in the
hospital for the second time. First time he was admitted was when he had
an appendectomy operation. He got no allergies to either food or drugs.
Aside from that, the patient told that his father have hypertension.
Familial medical history suggests that his mother had the same renal
problem. The family is a nuclear type. They are residing in Cagayan. He
has a wife and it is eight months pregnant. Their religion is Roman
Catholic.
Furthermore, the patient is not allergic to any kind of food.
According to his personal history, he is the eldest among them. He said
that he’s a non-smoker but an occasional alcoholic beverage drinker. He
prefers salty foods because for him it seems tastier than any other type of
food. He normally drinks about 3000 liters of water; however there are
times during their duty that he wasn't able to drink due to scarcity of the
resources.
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Nursing Management V
Nursing Physical Assessment
Mr. DBA was conscious and coherent at the time of assessment. The
patient’s temperature was 36.2 °C, respiratory rate was 22 cpm, pulse
rate of 80bpm and blood pressure of 130/80 mmHg. The client has a
medium body frame. He can stand and sit properly. He is well – groomed
upon assessment, he has no body odor. No deformity noted.
He has a good eye contact. Pupils are black, round and equal in size.
Sclera is white bulbar conjunctiva is clear, palpebral conjunctiva is pink
and lacrimal apparatus is moist. Eyebrows are thin and symmetrical.
However, there are presence of eyebags .
According to the patient, there is tenderness at his left flank area
before. The patient’s skin was warm to touch. Prior to admission, the
patient experienced left flank pain.
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According to Myers, pain often comes in waves. It has been said that
kidney stone pain is the worst pain that a man can experience. It radiates
towards the thigh and genitals.
Laboratory tests were done to find out some abnormalities on Mr.
DBA. Urinalysis showed that the urine was yellow & slightly turbid with 3P
Gravity: 1.610, microscopic analysis showed increased level of WBC. KUB
Ultrasound was the diagnostic tool used to the patient. It showed that both
kidneys are within the normal limits in size and configuration. Renal
Outlines are smooth and intact. Cortical echoes are homogenous.
However, there are several mid and inferior calyceal calculi noted in the
left causing mild superior caliectesia. The size range to 0.5 to 0.9 cm
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Our Lady of Fatima University Research and Development Center
Nursing Management
VI
Related Treatment
The patient had different medications being taken. The medications
that were given are the following: Rowatinex, 3 times a day before meal,
an anti-urolithic drug. It promotes diuresis and relaxes urinary tract spasm,
thus assisting the passage of stones. Liquid intake should be encouraged
during the therapy. Likewise, Irbesartan is also prescribed, 1 tab OD, for
hypertension, it decreases excess water and salt in the body. It may take
with or without food, drink plenty of water to prevent dehydration. On the
other hand, Celecoxib is being ordered to relieve pain as necessary. And
Ural sachet, a gastric alkanizer, used to relieve the symptoms
of infections in the urinary system or excessive gastric acid. This
medication is to be taken 3 times a day. Ural works to reduce the burning
sensation when passing urine and the discomfort experienced. It works to
increase the pH in the urinary and gastric system, therefore making your
urine less acidic.
In order to remove the stone that was located on mid and inferior
calyces in left kidney, medical procedure was performed to the patient.
And the intervention done was Extracorporeal Shockwave Lithotripsy
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(ESWL) therapy, a non-invasive alternative treatment. This procedure is
the most convenient way to remove the stones from the patient. The
successive shock wave pressure pulses result in direct shearing forces,
attempts to break up the stone with minimal collateral damage by using
an externally-applied, focused, high-intensity acoustic pulse.
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Nursing Management VII
Nursing Care Plan
The diagnosis for the patient was Sleep Deprivation related to
frequent urinary urgency as manifested by presence of eyebags and
frequent yawning upon the interview.
The plan for the patient is that after 2 hours of nursing intervention,
the client will be able to verbalized the causative/contributing factors of
his sleep deprivation,know the importance of enough sleep in our body
and understand proper sleep inducing techniques (Doenges and Murr,
2010).
Furthermore, after 1 day of nursing intervention, the client should
also be able to establish optimal sleep pattern
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The main nursing intervention to the patient is to provide adequate
sleep by understanding the following:
The patient must be taught about determining presence of physical
or psychological stressors, including recent illness (calyceal calculi). This is
done so that it will provide comparative baseline.
Likewise, it is also important to determine client’s usual patterns and
expectations and ascertain duration of current problem and effect
life/functional ability. This helps identify appropriate options and assists
client understand the importance of achieving enough sleep
Another aspect of promoting sleep is to note factors affecting sleep
such as increased fluid intake during night to determine the underlying
cause of his problem
Moreover, it is also essential to enumerate what are the benefits of
sleep in our health and encourage client to develop plan to restrict
caffeine, alcohol, and other stimulating substances from late/evening
intake. Instead he may drink milk if not contraindicated. This is to
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decrease tension and prepare for rest/sleep and to discuss factors that are
known to disrupt sleep pattern. Caffeine significantly affects visual
vigilance, choice reaction time, repeated acquisition, self-reported fatigue
and sleepiness
The need for observing for physical signs of fatigue (e.g.
restlessness)is also so important for a patient with this disorder. A chronic
sleep-restricted state can cause fatigue and generalized body weakness
In evaluating the patient’s understanding of this plan, the patient
was able to report improvement in sleep pattern as manifested by the
causative/ contributing factors of sleep deprivation and knowing
importance of enough sleep
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Our Lady of Fatima University Research and Development Center
Nursing Management
VIII
Recommendations
In the development of an individualized planning for patient DBA
prior to leaving hospital, with the aim of improving patient outcomes, we
have come up with the following guidelines in ensuring the following
management.
First, instructing patient to take prescribed medications regularly
and comply with the treatment regimen prescribed by the physician.
Compliance to appropriate medication and treatment prevents further
complications and promote continuous recovery of optimal health.
Moreover, we should teach patient regarding the names of the drug, its
dosage, time of administration, its contraindication and side effects. The
patient has the right to know his drug’s therapeutic effects as well as its
adverse effects. He also has the right to gain awareness about why is it
given to him. Likewise, we should also educate the patient and the
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significant others about the expected responses of drug to the body, side
effects, adverse effects that may possibly seen into the patient in order
for him to be geared up of enough information that may lead to
immediate medical responses .
Second, we also think that explaining to patient the significance of
regular exercise like walking and stretching is important. Increasingly,
there is evidence that a physical exercise program, integrated into
management plan, has positive benefits for general health, including
weight loss, improved muscle strength, lower level of cholesterol and
blood fats, increased cardiac output and greater physical exercise
capacity. Many of these benefits will also lower risk of heart disease, a risk
which is greater for people with kidney disease than among the general
population. In the case of patient DBA, there are no restrictions in physical
activities, for as long as he practices proper voiding habits.
In addition, home medications are also recommended. It includes
the following: sambong supplement can be included as it contains
powdered leaves of the sambong plant. It helps to dilute stones in the
urinary tract and act as a diuretic. Celecoxib is recommended if the
patient feels moderate to moderately severe pain.
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Next is considering the diet of patient DBA. A mixed balanced diet
with contributions from all food groups, but without excesses of any
kind .Fruit and vegetable intake should be encouraged because of the
beneficial effects of fiber. The alkaline content of a healthy diet also gives
rise to a desirable increase in urinary pH. Furthermore, Animal protein
should not be ingested in excessive amounts, and it is recommended that
animal protein intake is limited to 0.8-1 g/kg body weight. An excessive
consumption of animal protein gives rise to several unfavorable effects on
stone formation, such as hypocitraturia, low pH, hyperoxaluria and
hyperuricosuria. Aside from that, Encouraging client to increase fluid
intake is vital. In patients with an expected low risk of recurrent stone
formation advice on fluid intake and diet may be sufficient to prevent
stone recurrence. The positive effect of such a regimen has been referred
to as the ‘stone clinic effect’
Lastly, warning signs such as fever and Hematuria for more than 3
days may indicate immediate remedial action response. A follow-up visit in
the hospital serves as an evaluation process to note if condition has
progressed to better or worse.
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Nursing Management
IX
References
Books:
1. Myers, Jeffrey W., Neighbors, Marianne, Tannehill-Jones, Ruth (2002);
Principles of Pathophysiology and Emergency Medical Care,
Thomson Learning Inc., Clifton Park, NY
2. Stamatelou, Kiriaki K.; Francis, Mildred E.; Jones, Camille A; Nyberg
Jr., Leroy M.; Curhan, Gary C. (2003). "Time trends in reported
prevalence of kidney stones in the United States: 1976–1994"
3. Taylor EN; Stampfer MJ; Curhan GC (2004). "Dietary factors and the
risk of incident kidney stones in men: new insights after 14 years of
follow-up."
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4. No More Kidney Stones by John S. Rodman, M.D., R. Ernest Sosa,
M.D., and Cynthia Seidman, M.S., R.D, with Rory Jones.
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